Psychological Burden of Endometriosis During Assisted Reproduction

Beyond infertility: depression disproportionately affects women with endometriosis during IVF/ICSI

Key Points

Highlights:

• Among women undergoing IVF/ICSI, endometriosis is associated with a significantly higher prevalence of clinical depression.
• Across fertility settings, severe deep dyspareunia—rather than infertility status alone—emerges as the strongest predictor of anxiety and depression.

Importance:

• Identifying pain-specific markers such as deep dyspareunia enables early recognition of patients at high psychological risk, allowing timely mental health support during fertility treatment.

What’s done here?

• An observational cohort study was conducted at a university hospital between November 2023 and May 2024.
• A total of 324 women were included, comprising patients undergoing IVF/ICSI and those pursuing elective fertility preservation.
• Psychological status was assessed on the day of oocyte retrieval using a standardized 55-item questionnaire, including the Hospital Anxiety and Depression Scale (HADS).
• Endometriosis was rigorously diagnosed and staged using expert transvaginal ultrasound and/or MRI.

Key results:

• In the IVF/ICSI group, depression was significantly more frequent among women with endometriosis than controls (5.5% vs. 0.8%).
• In the fertility preservation group, current depression rates were low; however, women with endometriosis had higher prior use of psychotropic medication (13.2% vs. 2.2%) and greater engagement with psychological support services (21.1% vs. 4.4%).
• Severe deep dyspareunia was associated with a 2.7-fold increase in the odds of anxiety or depression.
• Active infertility treatment appears to amplify the emotional burden of endometriosis compared with elective fertility preservation.

Strenghts and Limitations:

• This is the largest study to date focusing on the psychological impact of endometriosis within these specific fertility contexts, utilizing validated tools and expert imaging.
• The study was conducted at a single center and had a 41% response rate, which may limit how well the findings apply to all populations.
• Additionally, the data represents a single point in time rather than tracking changes over a long period.

From the Editor-in-Chief – EndoNews

"This study succeeds because it refuses a simplistic narrative. Psychological distress in endometriosis is often attributed to “infertility stress,” yet these data suggest a more clinically useful truth: context modulates vulnerability, but pain—especially deep dyspareunia—acts as a biologically anchored alarm signal.

The IVF/ICSI finding is notable, but the real value lies in the comparison group. Fertility preservation is frequently treated as an emotionally safer setting, and yet the elevated history of psychotropic medication use and prior psychological support in the endometriosis subgroup argues against that assumption. It implies a chronic psychological load that may not be captured by a single time-point screen on retrieval day. In practice, this is exactly how risk gets missed: low “current” scores can coexist with meaningful prior morbidity.

Clinically, deep dyspareunia emerges here as more than a symptom—it is a triage marker. Severe dyspareunia likely concentrates multiple drivers of distress: persistent nociception, central sensitization, relationship strain, avoidance behaviors, and reduced sense of bodily safety. When this pain signature is present, asking only “How are you coping?” is insufficient; it should trigger structured screening and a proactive care pathway.

The message for assisted reproduction teams is straightforward: endometriosis management cannot be reduced to staging, protocol choice, and follicle counts. Integrating pain phenotyping with mental health screening should be standard, not exceptional—particularly at the moment patients enter IVF/ICSI, when pressure, uncertainty, and symptom burden converge. A multidisciplinary model is not a luxury; it is the evidence-based response to a disease whose impact is simultaneously pelvic and psychological."

Lay Summary

For many women, endometriosis is not only a fertility-related diagnosis but a long-term pain condition that can shape daily functioning, intimate life, and emotional well-being. When fertility decisions are on the table, this burden may intensify in distinct ways.

In this study published in Fertility and Sterility, Dr. Pietro Santulli and colleagues investigated whether mental health differs between two fertility contexts: women actively trying to conceive through IVF/ICSI and women choosing fertility preservation by freezing oocytes. Participants completed validated screening for anxiety and depression on the day of oocyte retrieval, and endometriosis was carefully defined using expert imaging.

The study found that in the IVF/ICSI setting, depression was significantly more common among women with endometriosis than among controls. In the fertility preservation setting, current depression was uncommon; however, women with endometriosis were much more likely to report prior use of psychotropic medication and prior psychological support—suggesting an existing, often underrecognized mental health burden.

A particularly important finding was that severe pain during intercourse (deep dyspareunia) strongly signaled vulnerability to anxiety and depression across fertility contexts. In other words, the severity of pain—not only infertility status—may be a key driver of psychological distress.

Overall, the results support a broader approach to endometriosis care during fertility treatment: alongside reproductive planning, clinicians should actively assess pain severity and offer timely psychological support, especially for those with severe dyspareunia or undergoing IVF/ICSI.

Research Source: https://pubmed.ncbi.nlm.nih.gov/41419108/